August 2015 NEWSIn this Issue:SWYC Screening Tool Adapted for Massachusetts

Need Help for Young Patients with Behavior Problems?

SBIRT – What Is It?

You Spoke...We Listened

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Leadership:John Straus, MD Founding Director

Barry Sarvet, MD Medical Director

Marcy Ravech, MSW Director

1000 Washington St., Suite 310 Boston, MA 02118E-mail: mcpap@valueoptions.com

www.mcpap.org

MCPAP is funded by the Massachusetts Department of Mental Health

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More than Prescribing: Five Ways Primary Care Providers Can Help Children with Attention Deficit Hyperactivity Disorder (ADHD) and Their FamiliesSharon Saline, Psy.D.

Anne* and her husband, Victor, came into my office for an initial parent visit looking tired and worried. Their daughter, Olivia, aged 9, had recently received a diagnosis of ADHD, Combined type, from her pediatrician. They appreciated how their physician validated their concerns and offered hope about their daughter’s situation. Anne summarized: “Our pediatrician was helpful in recommending that we read “Drivento Distraction” and referring us for testing and to your practice and website. She was supportive and receptive to our concerns but she wasn’t able to target interventions about living with ADHD that fit our daughter. We wanted something more.”

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Five Ways Primary Care Providers Can Help Continued from page 1

How can pediatricians offer ‘something more’ to these patients and their families given the constraints of short office visits and large patient caseloads? Primary care physicians already do a lot: assessment, diagnosis, medication management, basic education and treatment planning. Yet, it is possible to do ‘more’ without adding stress to your work.

Many parents of children and teens with ADHD do not fully appreciate how the disorder impacts all areas of their child’s functioning or why medications don’t address every one of the issues they are seeing. As pediatricians, you are perfectly poised to bridge this gap in understanding. You have likely known the child or teen for many years and witnessed the unfolding of the behaviors that have now been diagnosed as ADHD. As their primary ally, families trust you to help them figure out this complicated disorder and offer advice.

The following tips can help you monitor kids systematically through their regular visits so you can do ‘more’ relatively easily. Parents and kids alike crave solutions for their frustrations, for managing behavioral and academic challenges, and for finding ways to support each other. By focusing on how ADHD is affecting kids in each stage of their development and offering a few ideas to increase knowledge and acceptance of the disorder, you can provide this additional, critical assistance toyour patients.

Normalize the family’s experience

No one wants to think that they are disturbed or, even worse, that their child is deviant. Just by dealing with ADHD in a primary care setting, you already send the family a strong message that their child is not abnormal since the pediatric practice is a place people go for routine issues.

• It is very important to reassure kids that ADHD is a biologically based, skill deficit problem – NOT a personal flaw. Otherwise, they start to think of themselves in all types of negative ways. Olivia told me that doctors should “let the kid know that there’s nothing wrong with having ADHD.” Focusing on skills and biology reduces some of this embarrassment.

• To further reduce the possible shame relatedto the diagnosis, discuss the frequency of ADHD in the population and identify people the child or family may know personally or from sports or entertainment who have attention issues. Some include: Michael Phelps, Justin Timberlake, and Britney Spears to name a few.

• Talk about a treatment plan, including medication, referrals for psychological or educational testing, or recommendations for therapy, in the context of creating successes where there have been challenges or even failures. Both parents and children want to know that things can get better and will appreciate your reassurance.

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MCPAP News August 2015

Skills matter asmuch as pills

Medications for ADHD have been found to be the best treatment for reducing the symptoms associated with this disorder: lack of focus, hyperactivity, poor concentration, and difficulty attending to a task at hand. However, medication does not fully address the executive functioning deficits that go hand-in-hand with the ADHD diagnosis.

• Help children and parents understand theareas of executive functioning which are most challenging for the child. (See table on page 7).

• Encourage families to target one or more of theseareas for improvement. While there are many books available for parents to work on building executive functioning skills with kids on their own, it usually is most helpful for this process can happen in school, with a learning specialist, or in behavioral family therapy with a mental health professional.

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Five Ways Primary Care Providers Can Help Continued from page2

The American Academy of Pediatrics (AAP) clinical practice guidelines offer some key action statements that help primary care clinicians evaluate, diagnose, treat, and monitor children and adolescents with ADHD.

One such action statement is:

Conduct a face-to-face follow-up visit on a monthly basis during

initial stage, and then follow up with subsequent visits every three months

in the first year of treatment. Subsequent visits occur

at least twice a year.

Following AAP guidelines will give a practice a 100 percent score on the HEDIS® ADHD measure that many health plans use!

Advice from the American Academy of Pediatrics (AAP)

ADHD: Clinical Practice Guidelines

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MCPAP News August 2015

Acknowledge the emotional dysregulation associated with ADHD

Kids with ADHD often experience what I call “the tidal wave of feeling”: when an emotion gets too strong, it seems to flood the brain and they cannot control themselves or their behavior. While ADHD is usually seen as a disruptive, impulsive disorder and classified in the DSM-V as such, there is a significant component of mood instability as well.

• Children with ADHD and their parents need help understanding that there is a biological basis for this ‘flooding’ and that they can improve their abilities for modulation.

• Reminding parents of the importance of establishing structure (i.e., consistency of household routines, rules, limits) can help with emotional dysregulation.

• Help parents to recognize early warning signs of emotional “melt-downs” and to develop strategies for de-escalation. These strategies may include both the parent and child taking a “time-out” when emotions are flaring up. Parents may be aware of some activities which are calming or soothing to the child that can be implemented in the early stages of escalation. A psychotherapy referral may be useful for more attention to this issue.

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Five Ways Primary Care Providers Can Help Continued from page 3T

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SWYC Screening Tool Adapted for Massachusetts

Massachusetts has created a revised version of the Survey of Well-being of Young Children (SWYC) screening tool to in order toaddress postpartum depression asa critical issue in the development and well-being of infants and young children. In this SWYC/MA version, the Edinburgh Postnatal Depression Scale was added to the 2, 4, and 6-month forms. All of the other parts of the SWYC/MA at these three ages are identical to the generic SWYC. The remaining age-based forms remain unchanged. The SWYC/MA is available on the MCPAP website on the “For Providers” tab under “Screening & Toolkits” or at www.mcpap.com/Provider/ScreeningNToolkits.aspx. The SWYC/MA is a MassHealth-approved screening tool. In another piece of good news, MassHealth has announced they will begin paying for postpartum depression screening in 2016!

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MCPAP News August 2015

Five Ways Primary Care Providers Can Help Continued from page 4

Emphasize the importance of positive feedback

Self-esteem is a pivotal issue in children and teens with ADHD. It is not only a major contributor to co-morbid depression but also leads to giving up, not caring and failure. These kids are at high risk for losing their drive and their pride.

Kids with ADHD often develop a deep-seated sense of shame about having this diagnosis. Sometimes this shame is obvious: one girl can’t seem to make friends and spaces out at her desk at school. Sometimes it is more hidden: a boy boasts about his accomplishments at video games but procrastinates endlessly before starting homework. Either way, the shame about not being able to succeed at school or manage life tasks as well as other kids starts early in life and continues into adulthood.

Positive feedback about what the child or teen is doing well can reduce this shame and build self-esteem.

• Many ADHD kids expect to hear negative comments about themselves. When I asked Kyle, age 13, in a family session how he would like to receive feedback about his behavior, he paused, frowned and said, “I don’t. There is nothing good about feedback.”

• In order to create more balanced perceptions about feedback, these kids would benefit from changing the ratio of positive statements to negative ones. Encourage parents to try a 5:1 ratio for positive comments to corrective statements with their children and adolescents.

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Triple P: Positive Parenting Program is available!If you hear these complaints from parents:

• Hitting siblings

• Biting at day care

• Crawling into bed every night with parents

• Persistent thumb-sucking

• Never listens to me!

• Tantrums every time we do errands

Make a referral to your MCPAP Hub for Primary Care Triple P*. In two to four brief sessions, most parents will see a decrease in their children’s problematic behaviors, and they will have a much more enjoyable parenting experience.

For more information about Triple P contact your MCPAP team.

*If you have an accredited Primary Care Triple P provider within your practice, refer your patients directly to him/her.

Need Help for Young Patients with Troublesome Behaviors?

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MCPAP News August 2015

Five Ways Primary Care Providers Can Help Continued from page 5

• Praise works best when it is used for both efforts and accomplishments and is delivered immediately, with specific details. For example, “Thanks for setting the table and I notice that you put the forks and spoons in the glasses. That’s creative.” Or, “You did a good job getting back to your homework after dinner. I like that I didn’t have to yell at you to do that.”

When positive feedback is direct and precise, kids not only absorb and retain it better but also feel a sense of progress and competency.

Befriend Technology

Children and teens with ADHD need morereminders than other youngsters and often feel like they are being nagged. Technology, although a frequent source of distraction, can be extremely helpful in providing kids with ADHD the cues they need and simultaneously reduce the “nagging” factor.

• Parents can use cell phones, iPods and other devices to help kids improve their organization, reduce forgetfulness and learn to be more independent since they usually carry such devices with them at all times.

• The phone or iPod can become a useful reminding instrument. Parents can work with their ADHD child to set alarms for chores, homework times, work breaks, appointments and even turning in assignments. This helps build responsibility and self-reliance.

• It’s critical NOT to overuse this method. Encouragefamilies to pick ONE and only one task that their teen or child forgets to do and, together, set the alarm for that event. Now, the alarm cues the child or teen to do it instead of the parent. Parent follow up, however, is usually necessary.

• When there is success with this one thing, then the parent can add in another, but NO MORE than three per day.

While there are many detriments to technology and how teens, especially, overly focus on it, putting it to good use to help build time management and organization skills takes youthful fascination with gadgets and utilizes it to their advantage.

For further parenting tips related to ADHD, please see my monthly blog at drsharonsaline.com. You can also follow me on Twitter @drsharonsaline.

*All names and identifying information have been changed.

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About – the –Author

Sharon Saline, Psy.D. is a clinical psychologist in private practice in Northampton, MA where she works primarily with children, adolescents and families addressing concerns related to ADHD, learning disabilities and general mental health issues. She has taught and lectured nationally and internationally on topics related to child and adolescent development, ADHD and parenting. Dr. Saline has consulted extensively with schools in the Pioneer Valley on mental health issues in the classroom, improving teacher/parent communication and understanding psychological evaluations.

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EF SKILL DESCRIPTION

EF Skills related to behavior

INHIBIT RESPONSES: capacity to refrain from saying or doing things using reflection.

REGULATE EMOTIONS: ability to manage feelings by thinking about goals and impact of feelings on self and others.

INITIATE TASKS: ability to recognize when it is time to get started on something and begin it without too much procrastination.

FLEXIBILTY: capacity to change plans in light of complications, errors or problems.

GOAL PERSISTENCE: capacity to set objectives and meet them without being waylaid by competing interests; navigate between immediate and delayed gratification.

EF skills related to thinking

WORKING MEMORY: ability to hold information in mind and use it to complete a task; computational space in the brain.

ORGANIZATION: capability to create and maintain systems to keep track of information, responsibilities and stuff.

TIME MANAGEMENT: ability to understand how to assess, allocate and budget time accurately for tasks.

PLANNING AND PRIORITIZING: capacity to divide tasks and problems into parts while identifying what is most important in order to create solutions and achieve goals.

METACOGNITION: ability to monitor and evaluate your own actions and performance, reflect on yourself and see how you affect others.

HOW IT LOOKS IN CHILDREN & TEENS

Stops and thinks before doing or saying something.

Controls feelings, especially anger; has patience and tolerates frustration; doesn’t get upset about little things.

Gets started on chores or homework and finishes them efficiently, often without direction and excessive reminding.

Adjusts quickly to changes in schedule or plans; makes transitions between classes or activities smoothly; keeps trying even if it is hard to figure something out.

Sets clear goals easily; sticks with something even if it is boring; returns to task right after interruption.

Remembers things well; recalls and follows steps in a series of directions; turns in homework on time.

Keeps locker, bedroom, notebook, etc. clean and neat; can find things when needed and rarely loses items.

Does things on time and meets deadlines; can correctly estimate how long something will take; doesn’t procrastinate a lot.

Knows where to start on big projects and doesn’t find them overwhelming; readily decides what is most important when there are multiple things to do.

Has awareness of how own behavior impacts other people; responds positively to feedback; demonstrates appropriatejudgment; wants to learn from mistakes.

Executive Functioning Skills: Definition and Examples(Executive functions (EF) describe the directive capacities of the brain, specifically the functions of the pre-frontal cortex. Working together in different combinations, they prioritize, initiate and control other cognitive functions and manage the self-regulation of the brain. ADHD impairment lies in the ability to start and manage these functions in the right order at the right time.) [This chart is referred to in Tip 2 on page 3])

Five Ways Primary Care Providers Can Help Continued from page 6

MCPAP News August 2015

Bibliography: “ADHD: Clinical practice guidelines for the diagnosis, evaluation and treatment of Attention-Deficit/Hyperactivity Disorder in children and adolescents.” Pediatrics, Volume 128, Number 5, November 2011.Brown, T. (2014). Smart but stuck: Emotions in teens and adults with ADHD. San Francisco: Wiley and Sons. Dawson, R. & Guare, P. (2009). Smart but scattered. New York: Guilford.Gottman, J. (1994). Why marriages succeed or fail . . .and how you can make yours last. New York: Simon and Schuster.Hallowell, E.M. & Ratey, J.J. (1994/2011). Driven to Distraction: Recognizing and coping with attention deficit disorder from childhood through adulthood. New York: Anchor.Losada, M. & Heaphy, E. (2004). “The role of positivity and connectivity in the performance of business teams: A nonlinear dynamicsmodel.” American Behavioral Scientist, 47(6), 740–765.

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MCPAP News August 2015

Screening, brief intervention and referral to treatment, or SBIRT, is an evidence-based approach used to identify, reduce and prevent use of alcohol and other substances that result in adverse health outcomes, accidents and injuries.

Thirty-eight percent of pediatric providers in Massachusetts reported in a 2013 random-sample survey that they have insufficient time to screen for alcohol during office visits, suggesting they need a more efficient format.1 According to Dr. Sharon Levy, MD, MPH, Director of the Adolescent Substance Abuse Program at Boston Children’s Hospital, “To be practical in the busy medical office setting, screening must quickly and accurately triage adolescents into risk categories that determine the appropriate level of intervention.2 Consequently, she and her colleagues developed the S2BI

which stands for Screening to Brief Intervention, an algorithm designed specifically for use in the pediatric primary care setting and recommended by the American Academy of Pediatrics.

In collaboration with the MA Department of Public Health Bureau of Substance Abuse Services, the MA Department of Mental Health, and MCPAP, Dr. Levy has created a new SBIRT Toolkit featuring the S2BI, which can be ordered free of charge at https://massclearinghouse.ehs.state.ma.us/ by mid-September.

MCPAP is pleased to offer training to our enrolled practices on this new screening and brief intervention tool on-site at your

practice, via live webinar, or through grand rounds at your

local medical institution. To schedule a training or

for more information, please contact your MCPAP Hub.

1 MCPAP News October 2014

2 Levy, Sharon, Weiss, R., Sheritt,L., Aiemnik, R., Spalding, A., Van Hook, S., & Shrier, L.A. (2014). An Electronic Screen for Triaging Adolescent Substance Use by Risk Levels. JAMA Pediatrics. Retrieved from http://www.ncbi.nlm.nih.gov/ pubmed/25070067

What is it?SBIRT

We also know that providers want and need support for what to do when an adolescent screens positive. As always, our MCPAP teams are prepared to support your practice with consultation and care coordination.

You can view additional information on S2BI in the October 2014 issue of MCPAP News at http://www.mcpap.com/pdf/MCPAP NEWSLETTER Final.pdf. It is our goal to ensure that every adolescent in Massachusetts is screened for alcohol and drug use. To schedule a training or for more information, please contact your MCPAP Hub.

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MCPAP News August 2015

You Spoke...We Listened

Keep in mind that if you use email to communicate Personal Health Information (PHI), you must use a secure, encrypted system. Similarly, you will need a password to open communications from the MCPAP team returned to you securely.

We want to make the MCPAP consultation experience as effortless as possible. The following are communications that can be handled easily via email:

• Requests for call-back during a specific time-frame; unless previously discussed with your psychiatric consultant or care coordinator please provide a time range rather than a specific time, i.e., after 4:00 pm or between 2:00 and 3:00 pm.

• Requesting face-to-face evaluations (after a phone consultation) and/or providing information for scheduling.

• General questions that are not about a specific patient.

Email is not appropriate or a replacement for clinical consultation. You may send a request for consultation with the clinical information, and you may request a call-back within a specific time frame. However, our psychiatric consultants will not be able to provide the same child-specific consultation currently provided by phone, via email. Email is never appropriate for urgent or emergent situations.

Remember that MCPAP child psychiatrists rotate schedules. If you email a request on Monday evening, you will receive a response on Tuesday from the psychiatrist covering MCPAP that day. However, if you email a specific team member and want a response from that team member, you may have to wait until that psychiatrist’s scheduled MCPAP day.

If you would like to begin using email with your MCPAP Hub, please contact your MCPAP Care Coordinator for appropriate email addresses and to confirm the process. We do ask that on any email correspondence you ALWAYS copy the team’s care coordinator.

We received many requests on the Annual Provider Experience Survey to offer email communication between enrolled primary care providers and our MCPAP Hubs. Team members already use email with some practices and in other instances they are able to utilize clinical notes in shared electronic health records.